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Background

Premature ejaculation (PE; also known as rapid ejaculation) is the most common type of sexual dysfunction in men younger than 40 years. Most professionals who treat premature ejaculation define this condition as the occurrence of ejaculation prior to the wishes of both sexual partners. This broad definition thus avoids specifying a precise duration for sexual relations and reaching a climax, which is variable and depends on many factors specific to the individuals engaging in intimate relations. An occasional instance of premature ejaculation might not be cause for concern, but, if the problem occurs with more than 50% of attempted sexual relations, a dysfunctional pattern usually exists for which treatment may be appropriate.

To clarify, a male may reach climax after 8 minutes of sexual intercourse, but this is not premature ejaculation if his partner regularly climaxes in 5 minutes and both are satisfied with the timing. Another male might delay his ejaculation for a maximum of 20 minutes, yet he may consider this premature if his partner, even with foreplay, requires 35 minutes of stimulation before reaching climax. If intercourse is the method of sexual stimulation for the second example and the male climaxes after 20 minutes of intercourse and then loses his erection, satisfying his partner (at least with intercourse), who needs 35 minutes to climax, is impossible.

Because many females are unable to reach climax at all with vaginal intercourse (no matter how prolonged), this situation may actually represent delayed orgasm in the female partner rather than premature ejaculation in the male; the problem can be either or both, depending on the point of view. This highlights the importance of obtaining a thorough sexual history from the patient (and preferably from the couple).

The criteria for premature ejaculation stated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, text revision (DSM-IV-TR) is as follows: (1) persistent and recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration before the person wishes it; (2) marked distress or interpersonal difficulty; and (3) not exclusively due to direct effects.

The human sexual response can be divided into 3 phases: desire (libido), excitement (arousal), and orgasm. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classifies sexual disorders into 4 categories: (1) primary, (2) general medical condition–related, (3) substance-induced, and (4) not otherwise specified. Each of the 4 DSM-IV categories has disorders in all 3 sexual phases.¹

Premature ejaculation may be primary or secondary. Primary premature ejaculation applies to individuals who have had the condition since they became capable of functioning sexually (ie, postpuberty). Secondary premature ejaculation means that the condition began in an individual who previously experienced an acceptable level of ejaculatory control, and, for unknown reasons, he began experiencing premature ejaculation later in life. Secondary premature ejaculation does not relate to a general medical disorder and is usually not related to substance inducement, although, rarely, hyperexcitability might relate to a psychotropic drug and resolves when the drug is withdrawn. Premature ejaculation fits best into the category of “not otherwise specified” because the cause is unknown, although psychological factors are suggested in most cases.

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Pathophysiology

Premature ejaculation is believed to be a psychological problem and does not represent any known organic disease involving the male reproductive tract or any known lesions in the brain or nervous system. The organ systems directly affected by premature ejaculation include the male reproductive tract (ie, penis, prostate, seminal vesicles, testicles, and their appendages), the portions of the central and peripheral nervous system controlling the male reproductive tract, and the reproductive organ systems of the sexual partner (for the purpose of this discussion, the partner is assumed to be female) that may not be stimulated sufficiently to achieve orgasm.

If the premature ejaculation occurs so early that it happens before commencement of sexual intercourse and the couple is attempting pregnancy, then pregnancy is impossible to achieve unless artificial insemination is used. Perhaps the most affected organ system is the psyche of the partners. Both partners are likely to be dissatisfied emotionally and physically by this problem.

From an evolutionary perspective, logic may dictate that males who can ejaculate rapidly would be more likely to succeed in fertilizing a female than males who require prolonged stimulation to reach climax. The genes of a male who ejaculates rapidly (but not so rapidly that ejaculation occurs before intromission) would be more likely to be passed on to succeeding generations. In a primitive sense, a male who could not complete the fertilization process quickly might be pushed away or killed by a competing male because of his obvious vulnerability during intercourse.

Premature ejaculation has historically been considered a psychological disorder. One theory is that males are conditioned by societal pressures to reach climax quickly because of fear of discovery when masturbating as teenagers or during early sexual experiences “in the back seat of the car” or with a prostitute. This pattern of rapid attainment of sexual release is difficult to change in marital or long-term relationships. The fact that female arousal and orgasm require more time than male arousal is being increasingly recognized, and this may result in increased recognition and definition of premature ejaculation as a problem.

Some have questioned whether premature ejaculation is purely psychological. A number of investigators have found differences in nerve conduction/latency times and hormonal differences in men who experience premature ejaculation compared with individuals who do not. The theory is that some men have hyperexcitability or oversensitivity of their genitalia, thus preventing down-regulation of their sympathetic pathways and delay of orgasm. Recently, a certain group of nerves in the lumbar spinal cord has been identified as the possible generator of ejaculation. This nerve site is thought to be linked to excitatory and inhibitory dopamine pathways in the brain, which play significant roles in sexual behavior. This knowledge, while continuing to be researched, is providing the foundation for possible development of medications specifically targeting delay of ejaculation.²

Other questions have been raised regarding possible biochemical factors in premature ejaculation. Testosterone is thought to play a role in the ejaculatory reflex. Higher testosterone (free and total) levels have been demonstrated in men with premature ejaculation than in men without premature ejaculation.³

Research published in a Chinese andrology journal showed that semen from men with premature ejaculation contained significantly less acid phosphatase and alpha-glucosidase than did the semen of controls.⁴ These researchers concluded that these biochemical parameters may reflect dysfunction of the prostate and epididymis, possibly contributing to premature ejaculation; however, these have yet to be supported by subsequent studies.

In other biochemical parameters, many men with premature ejaculation have been shown to have low serum levels of prolactin.⁵ However, in this same study of prolactin in men with sexual dysfunction, men in the lowest quartile of serum prolactin levels who had premature ejaculation also demonstrated associated metabolic syndrome, erectile dysfunction, and anxiety. In other words, while biochemical markers such as prolactin may contribute to premature ejaculation, organic and psychological associations (ie, anxiety) suggest that biochemical parameters play only a partial role in premature ejaculation. Further research is needed.

While other factors may play roles of unknown significance, psychological factors have been found to contribute greatly to premature ejaculation beyond merely the time to ejaculation. While patients with premature ejaculation show significantly lower intravaginal ejaculatory latency time (IELT), the IELT in those who fit the DSM-IV-TR criteria for premature ejaculation overlaps with the IELT in patients who do not fit the criteria.⁶ However, while a shorter IELT has been the measure of premature ejaculation in many studies, the perception of ejaculation control has been shown to mediate patient and/or partner satisfaction with sexual intercourse and ejaculation-related distress.⁷ While premature ejaculation is most likely not a purely psychological disorder, such associations demonstrate a significant psychological role in the disorder.

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Frequency

United States

An estimated 30%-70% of American males experience premature ejaculation. The National Health and Social Life Survey (NHSLS) indicates a prevalence of 30%, which is fairly steady through all adult age categories. (In contrast, erectile dysfunction [ED] rises in prevalence with increasing age). However, various surveys have shown that many men do not report premature ejaculation to their physician, possibly because of embarrassment or a feeling that no treatment is available for the problem. Some men might not even perceive premature ejaculation as a medical problem. Such survey data suggest that the percentage of men who experience premature ejaculation at some point in their lives is almost certainly more than the 30% reported in the NHSLS.

International

Estimates of premature ejaculation in European countries and India mirror the prevalence in the United States.⁸ The prevalence in other parts of Asia, Africa, Australia, and elsewhere is unknown.

Mortality/Morbidity

No known direct morbidity or mortality results from premature ejaculation. Indirectly, premature ejaculation may alter self-esteem, may cause marital dysfunction, and may be a factor in depression, with its obvious consequences.

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Race

Although no reproducible data exist on major differences between racial groups with respect to the incidence or prevalence of premature ejaculation, a few recent surveys suggest that some racial variation may exist with respect to this condition. A telephone survey by Carson et al (2003) found in interviews of 1320 men without ED that 21% of non-Hispanic African Americans reported premature ejaculation, while 29% of Hispanics and 16% of non-Hispanic whites reported the condition. An analysis by Laumann et al (1999) of the NHSLS found that premature ejaculation was more prevalent among African American men (34%) and white men (29%) than among Hispanic men (27%).⁹

In a small study of a sexual health clinic in Australia, 59% of premature ejaculation diagnoses were in men of Asian or Middle Eastern descent, while 41% were of Western or European birth.¹⁰ However, drawing firm conclusions from these data is difficult in view of the small number of such studies and lack of suitable controls.

Sex

Premature ejaculation is a condition that only affects males.

Age

Premature ejaculation can occur at virtually any age in an adult man’s life. As a reported condition, it is most common in younger men (aged 18-30 y) but may also occur in conjunction with secondary impotence in men aged 45-65 years.

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Clinical

History

The history of the patient’s premature ejaculation (rapid ejaculation) is helpful because it ultimately guides the treatment that is best suited to the patient (and his partner). One should determine whether premature ejaculation is lifelong (ie, primary) or acquired (ie, secondary) and assess the severity of the problem.

For completeness, a general medical history should be taken to screen for other medical conditions that might be relevant. For example, if the patient has angina with subsequent fear of myocardial infarction during sexual activity, he might present with premature ejaculation when the actual underlying problem is his cardiac disease and his mental insecurity regarding his cardiac disease. Resolution of the cardiac problem usually solves the premature ejaculation, with no specific therapy for the premature ejaculation. For the purpose of this discussion, the patient is assumed to be healthy, and sexual dysfunction is the only significant problem.

If the patient has always experienced premature ejaculation from the time he began coitus, then he has primary premature ejaculation. If he had successful coital relationships in the past, yet began experiencing premature ejaculation with the current relationship, then he has secondary premature ejaculation. In most cases, secondary premature ejaculation is easier to treat and has a better prognosis.

• Primary premature ejaculation
  • In addition to the general medical history, inquire about any prior psychological difficulties, as psychiatric conditions are more common in males with primary premature ejaculation than in the general population.
  • The history should include questions about the patient’s early sexual experiences. Did he experience a traumatic sexual episode as a child or teenager? An example might be discovery by a parent during masturbation, with subsequent feelings of guilt. Alternatively, the patient may have been punished or threatened with punishment for masturbation.
  • Inquire about the patient’s family relationships while he was growing up. How did he relate to his mother, father, brother(s), sister(s)? Does his family have a history of incest or sexual assault? Males can be sexually assaulted by other males and, in rare instances, by females, including siblings.
  • What were peer relationships like? Did he have other male friends, any female friends? How does he regard himself with respect to peers (eg, inferior, superior, athletic, frail, more intelligent, less intelligent)?
  • Does the patient have any difficulties with work (or school, if still a student)?
  • What is the patient’s general attitude toward sex (ie, whether it is regarded as dirty), and what is the patient’s sexual preference, fantasy, and arousal pattern?
  • Did the patient have a strict religious upbringing? If so, what was he taught about sex?
  • If the premature ejaculation began with an initial nonmarital relationship, does he feel guilt about this?
  • If the first coital experience was within a marital relationship that involved premature ejaculation from the start, inquire about premarital, noncoital sexual play between the partners.
  • Ask about the sexual attitude and response of the female partner; if she is having a problem, such as dyspareunia, it could relate to the male’s problem or may have preceded it.
  • What is the nonsexual part of the relationship like? Does the couple fight or are they going through a power struggle?
  • If the patient’s sexual partner is not present for this interview, ask why (ie, whether the partner is not supportive or is blaming him).
  • Clues from these and similar questions usually point toward causation factors that may be addressed specifically with therapy.
• Secondary premature ejaculation
  • In addition to a general medical history, the history should include details about prior relationships in which premature ejaculation was not a problem for this individual and any prior relationships in which transient episodes of premature ejaculation occurred.
  • In the current relationship, was premature ejaculation always a problem or did it start after an initial time frame when coitus was satisfactory to both partners?
  • Inquire specifically about the quality of the relationship with respect to nonsexual factors. Do the partners get along on most issues, or is conflict present? Who is dominant in the relationship, or is the relationship generally equal?
  • Did the patient’s female sexual partner accompany him to the clinic? If not, ask why. She may regard the problem as only his rather than a problem of the couple, which may be an important clue.
  • Does he have an impotence problem? If he has erectile dysfunction (ED), did is begin after the premature ejaculation or before? If the patient does not have ED, what is the general timing for the male (ie, commencement of intromission to climax)?
  • Can actual coitus be achieved or is it prevented by premature ejaculation?
  • Is the patient experiencing premature ejaculation with self-stimulation (ie, masturbation), with nonintercourse stimulation by the partner, or just with coitus?
  • What is the time required for the female partner to reach climax? Can she reach climax with intercourse, or does she require direct clitoral stimulation (oral or manual) to be able to climax?
  • If the patient has ED that began after the premature ejaculation, then treatment of both conditions may be required; sometimes, the ED resolves when the patient gains confidence in controlling his ejaculation. If the ED started initially, the premature ejaculation may be a secondary sexual dysfunction, which resolves when the patient is confident in being able to maintain his erection.
  • Clarification of these and other factors usually proves very helpful when arriving at a treatment plan.

Physical

Physical examination findings are normal in males whose only presenting condition is premature ejaculation.

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Causes

The cause of premature ejaculation is considered psychological, although this has not been definitively confirmed.

• Primary premature ejaculation
  • In patients with primary premature ejaculation, in which the male has never experienced sexual relations without also experiencing premature ejaculation, a deep-seated emotional disturbance (see History) may be present and the causes may be multiple.
  • Sometimes, the behavior is a conditioned response resulting from teen masturbation practices (see Introduction), but, sometimes, the patient has deep anxiety about sex that relates to one or more traumatic experiences encountered during development. Examples may include family incest, sexual assault, conflict with one or both parents, or other serious disturbances.
  • In most cases, a primary care physician or a urologist should consult with a psychiatrist, psychologist, or other professional in cases of primary premature ejaculation.
• Secondary premature ejaculation
  • With regard to secondary premature ejaculation, some type of performance anxiety is often a major factor.
  • Performance pressure (ie, fear of failure to satisfy the partner) can arise from various precipitating events. ED is a common precipitating event. If the male is afraid his erection will not last, because of either actual instances of previous ED or imagined failure of his erection, this may precipitate premature ejaculation. The patient may have used the phrase, “Honey, you excited me so much I just could not hold back,” which might be a way for him to avoid admitting to the humiliation of being unable to keep his erection throughout intercourse. If he climaxes quickly, he then has an excuse to justify his inability to maintain his erection.
  • However, a careful history (see History) is needed because the situation may be complex.
  • Perhaps ED is not a part of the problem. Possibly, his partner has belittled him with comments such as “You must not be much of a man, since you cannot stay hard until I am satisfied.” In addition, she actually may have difficulty achieving climax through intercourse and may require direct clitoral stimulation to reach a climax. If she does not communicate this to him (and she may conceal it because of feelings about her own inadequacy), then he will always fail to provide coital satisfaction for her.
  • Because most physicians are not trained sex therapists, sorting out conflicts in the relationship and then referring couples for counseling to professionals with experience and training in that area is important. Physician who have some training or experience in the treatment of premature ejaculation and who are comfortable managing the problem may choose to begin treatment (eg, counseling, medication, both). If the patient does not respond favorably or if the physician is not comfortable with the treatment of premature ejaculation, then referral to a sex therapist, psychologist, or psychiatrist is the next step.

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